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Agrawal A et al

Health Renaissance 2013; Vol. 11 No.1; 83-85

Retained placenta in patient with valvular heart disease

Case Report

Management of retained placenta in patient with valvular heart disease

with pulmonary edema
A Agrawal1, A Thakur1, P Rijal1, P Basnet1, A Ghimire2, DK Uprety1
Department of Gynecology and Obstetrics, BPKIHS, Dharan, Nepal

Department of Aesthesiology and Critical Care Medicine, BPKIHS, Dharan, Nepal


A case of retained placenta following full-term vaginal delivery with an unscarred uterus
where surgical management of delivering the placenta was not attempted due to unfavorable
cardiac condition is presented. Although she was planned for hysterectomy, she was
successfully managed medically with injection methotrexate.

Introduction also been used to expedite resorption of placental

Retained placentas affect 0.5%3% of women tissue.68
following delivery, and is a major cause of maternal
death from postpartum haemorrhage (PPH) and Case report
puerperal sepsis.1, 2 After uterine atony, retained A lady, 21 years P1 L1, reported at BPKIHS, 16
placenta is the second major indication for blood hours following vaginal delivery, with retained
transfusion in the third stage of labour3. Independent placenta after failed attempt of MRP. She was
risk factors associated with retained placenta include conscious, with normal vital signs, moderately pale,
non-use of antenatal care, previous retained placenta, with a diastolic murmur at aortic area. Uterus was
previous caesarean section, maternal age 35 years 20-22 weeks size, well contracted with pelvic
or more, grand multiparity, previous dilatation and examination showing moderate amount of bleeding
curettage, preterm delivery and placenta weight less with patulous but closed cervical os and cord hanging
than 501 gm.4 The ensuing complications may out of vagina
include- severe post-partum haemorrhage with its Her investigations read hemoglobin 10.9gm/dl, total
resultant coagulopathy, postpartum curettage, uterine and differential counts within normal limits, with
perforation, shock, infection, loss of fertility and even normal readings of routine urine analysis, platelet
death. The conventional treatment is manual removal count, coagulation profile, hepatic and renal function
of placenta (MRP) under general anaesthesia(GA) tests. There was prolonged QT interval and T wave
followed by hysterectomy if it fails. Not only does inversion in electrocardiography. Echocardiography
this approach preclude future fertility, but it is also a showed concentric left ventricular hypertrophy,
procedure synonymous with significant perioperative severe aortic stenosis, severe aortic regurgitation,
risks. For women who wish to conserve their mild mitral regurgitation and tricuspid thickened AV
reproductive function, other treatment options have leaflets without pulmonary artery hypertension with
been described. In some settings, uterine conservation ejection fraction of 60%.
(with the placenta left in situ) may be an alternative On 4th post partum day, she was planned for MRP.
strategy.58 Adjuvant therapy with methotrexate has However, before GA, after inserting epidural catheter
she developed severe pulmonary edema. MRP was
__________________________________________________ postponed and she was shifted to maternal intensive
Address for correspondence
Dr Ajay Agrawal care unit (MICU) for further management.
Department of Gynecology and Obstetrics Considering the desire of the patient for retaining
BPKIHS, Dharan, Nepal
Email: drajayagrawal@yahoo.com
her uterus, conservative management was planned.

Agrawal A et al
Health Renaissance 2013; Vol. 11 No.1; 83-85
Retained placenta in patient with valvular heart disease

On sixth postpartum day transabdominal sonography uterus, after 18 days of hospitalization. On subsequent
revealed uterus of post partum size with endometrial follow-ups, for one month, patient remained afebrile
cavity showing an echogenic mass of dimensions with no evidence of infection, and normal sonographic
9.8cm x 8cm x 7cm, suggestive of placenta, with and colour doppler findings after a fortnight.
vascularity on colour doppler confirming it to be
adherent to the uterine wall (placenta accreta), but Discussion
with no definite invasion (figure 1). Modality adopted Presently, the only effective treatment of retained
was: placenta left in-situ and injection methotrexate placenta is MRP under GA. The role of systemic
given intramuscularly in the schedule of 1 mg/kg body oxytocics in the management of retained placentas
weight, weekly. Complete blood counts, liver and is controversial. Oxytocics given prophylactically at
renal function tests were done before giving each the time of delivery increase the number of placental
dose of methotrexate which remained within limits. deliveries at 20 and 40 minutes but have no effect
Injection folinic acid 0.1 milligram per kilogram body on the number of placentas that eventually need
weight was given twenty-four hours after manual removal9.Injection of oxytocin into the
methotrexate. umbilical vein has been suggested as an alternative.
Despite several placebo controlled trials of this
technique, no firm conclusions have been reached
regarding its efficacy.10
Methotrexate has also been described an as adjuvant
therapy for the conservative management of placenta
accrete. 58, 11 It has been hypothesized that
methotrexate acts by inducing placental necrosis and
expediting a more rapid involution of the placenta12.
This contradicts the belief that methotrexate acts
Figure 1: Placenta accreta only on rapidly dividing cells, given that trophoblast
proliferation is not felt to occur at term13. Thus, there
First dose of methotrexate was given on 6th post- is controversy as to the effectiveness of methotrexate
partum day after which she passed brownish vaginal as an adjuvant treatment. Also, there is a lack of
discharge along with bits of tissue. Broad spectrum consensus regarding optimal dosing, frequency, or
antibiotics and antiseptic vaginal douching was route of administration. Dose in this particular case
continued. Size of the uterus decreased remarkably was weekly 1 mg/kg body weight. In a recent review,
and on 9th postpartum day it was 14-16 week size. 0n conservative management was utilized in 167 cases
13th day second dose was given and her trans- of placenta accreta/percreta14.The failure rate was
abdominal sonography was repeated which revealed 22% and hysterectomy, either primary or delayed,
decrease in placental size. However on 16 th was required mostly for severe hemorrhage. Severe
postpartum day, at night she started to have moderate maternal morbidity, including one maternal death,
amount of vaginal bleeding, she was tachycadiac, with occurred in 6% of cases. The death was attributed
normal blood pressure without evidence of pulmonary to aplasia and nephrotoxicity secondary to
edema. On abdominal examination, uterus was 14 intraumbilical administration of methotrexate. This
weeks size, well contracted with pelvic examination case highlights the adverse effects that may occur
showing moderate amount of bleeding per vaginum following even a single dose of adjuvant methotrexate.
with patulous cervical os about two cm dilated. She Although conservative management of placenta
was planned for dilation and evacuation under accrete appears to be successful at preventing
paracervical block which was successfully performed hysterectomy in most cases, there is still potential
and about 150gm of placental chunk was removed. for morbidity. If such an approach is used, intensive
With this conservative strategy, vaginal bleeding monitoring for complications is required. Women may
never became alarming and vaginal discharge never continue to be at risk for weeks to months after
purulent. Patient was discharged in a satisfactory delivery. Sentilhes et al. reported a median period to
condition, fulfilling her initial desire of conserving the delayed hysterectomy of 22 weeks.14

Agrawal A et al
Health Renaissance 2013; Vol. 11 No.1; 83-85
Retained placenta in patient with valvular heart disease

Another controversy surrounding the use of abnormally invasive placentation, Obstetrical

methotrexate in the management of placenta accreta and Gynecological Survey, vol. 62, no. 8, pp. 529
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prognostic implications of decreasing hCG levels 7. G. Kayem, C. Davy, F.Goffinet, C. Thomas,D.
following administration of methotrexate are better Clement, andD. Cabrol, Conservative versus
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placenta accrete, it is not clear whether decreasing accreta, Obstetrics and Gynecology, vol. 104,
levels correlate with the rate of involution of placental no. 3, pp. 531536, 2004.
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9. Prendivllle WJ, Elbourne D, McDonald S. Active
Conclusion versus expectant management of the third stage
Our case demonstrates, conservative treatment of of labour (Cochrane Review). In :The Cochrane
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